By Andrea Gordon Living Reporter
Like most parents today, Nadine Silverthorne doesn’t chew over major child-rearing decisions without a heaping side dish of angst. And whether or not to vaccinate her two children is one of her biggest.
The Toronto mother has combed websites, blogged about childhood immunization and canvassed friends and family. She has polled her followers on Twitter and quizzed her doctor and homeopath. She remains torn.
Her two children reflect her conflict. Nate, 5, is up to date on a dozen injections Health Canada recommends for infants and young children to protect them from 11 diseases — including tetanus, polio, measles and meningitis. But 3-year-old Lucy has missed her last seven shots on the vaccine schedule.
“You want to be a good patient and you want to be a good citizen,” says Silverthorne, 36. “And yet I don’t know whether this is necessarily the best thing for my kids.”
She and her husband, Jan, didn’t think twice when it came to vaccinating Nate. By the time Lucy was born, Silverthorne, an editor for the lifestyle website Sweetspot.ca, had started monitoring the debate.
She says she gritted her teeth when Lucy was 2 months old and the pediatrician jabbed the 11-pound, six-ounce infant’s thigh with a half-millilitre cocktail of germs aimed at stimulating her immune system to fight off five diseases. As he injected the second needle, she recalls shuddering at the thought of all those bacteria and virus particles being blasted into her shrieking child before she was old enough to pop her first tooth.
Following those first shots, Lucy was miserable for days — sleeping fitfully, constipated, getting a bad cold. Same thing happened after her next shots at four and six months. Fussiness, fever and pain at the injection site are not uncommon side effects, but the physician said Lucy’s cold and constipation were unrelated. Still, it made Silverthorne uneasy. Lucy hasn’t been immunized since.
“I’m not vaccine averse,” she insists. “I’m one-size-fits-all-medicine averse.”
A generation ago, few parents questioned the merits of immunization, one of the big success stories of modern medicine. Vaccines were key in eradicating smallpox from the planet. Paralytic polio has been eliminated from most parts of the world.
But, increasingly, public-health officials — from the country’s chief medical officer of health to general practitioners — worry it is losing ground as a small (and often outspoken) minority delay or refuse to vaccinate their children. Many other parents follow their doctor’s advice, but that doesn’t mean they do so in the certainty that it’s the best course to take.
That parents are challenging the status quo was inevitable. This generation came of age during the green movement. They mistrust Big Pharma and question conventional medicine. They have lived through recalls of plastic baby bottles and toys tainted with toxic substances. They wonder whether public-health agencies have really got their backs.
On the Internet, anti-vaccination websites and YouTube clips have spread faster than a flu bug, suggesting that vaccines can cause a range of adverse side effects, from peanut allergies to asthma, and pointing to rare reactions such as seizures or neurological disorders. So have warnings from celebrities — notably U.S. actor Jenny McCarthy, who believes vaccines caused her son to be autistic.
A 1998 study led by Dr. Andrew Wakefield in the prestigious medical journal The Lancet suggested a link between childhood measles-mumps-rubella vaccine and autism, prompting many parents to skip the vaccine. The study was later discredited and withdrawn, and the journal issued a formal retraction this year, but the controversy left parents wondering what to believe.
Doctors offer assurance that the risk of serious side effects is extremely low, much lower than the dangers of the diseases. That said, finding reliable numbers for the risks of any vaccine is devilishly difficult.
Immunization is a victim of its own success. Today’s parents have no memories of playmates crippled by paralytic polio or who have suffered encephalitis or brain damage as a result of measles.
“The days when people would just come in and automatically roll up their kid’s arm are over,” says Dr. Val Rachlis, a Toronto family physician since 1974. “Parents are much more concerned about the safety versus the benefit of these vaccines.”
It’s hard to measure precisely how this debate has affected vaccination rates. Canada has no national registry to track how many people have fallen behind with their shots, though one has been in the works for seven years. Moreover, provinces use different methods of monitoring. There is a national immunization coverage survey conducted every two years by phone. But the most recent, involving about 1,600 households, was in 2006, using data from 2004. It found that only 61 per cent of 2-year-olds and 41 per cent of 7-year-olds were up to date with vaccinations for diphtheria, tetanus, polio, pertussis (whooping cough), hemophilus influenza type B (Hib) and the separate shot for measles, mumps and rubella.
Each vaccine-preventable disease requires a minimum level of immunization in the population (known as “herd coverage”) to stop a single case from triggering an outbreak. For highly infectious diseases such as polio or measles, it’s thought to be about 90 per cent, though public health targets are higher.
Ontario statistics provide a more accurate, but limited, view. Students in this province can be suspended or denied admission to school if they don’t have proof of immunization for six diseases: diphtheria, tetanus, polio, measles, mumps and rubella. Exemptions are granted for reasons that are medical, religious or for personal belief, but must be notarized by a lawyer.
Ontario records from the 2008/’09 school year show coverage among children ages 7 through 17 ranges from a low of 86 per cent for diphtheria to 92 per cent for polio. But even this data paints an incomplete picture because it doesn’t give a sense of how many regional pockets or specific schools have much lower rates than average and are more vulnerable to outbreaks.
Even the experts argue about immunization rates. A June editorial in the Canadian Medical Association Journal referred to rates of polio immunization hovering at about 80 per cent among Ontario children, the data apparently drawn from national stats. The province’s chief medical officer of health immediately wrote a letter to the editor, citing higher numbers.
Last year, a Toronto Board of Health report noted the lack of data about younger children and warned “a significant proportion of preschool children may be under-immunized.” It cited a study based on physicians’ billings that found about 75 per cent of 2 year olds in Toronto were up to date on recommended vaccines. The overall figure for Ontario was 66 to 70 per cent.
Muddying the water even further for parents is the growing roster of recommended shots, which can deliver up to five vaccines at once. Thirty years ago, Ontario children were inoculated against five illnesses. Today, by the time a child has finished grade school, he or she will have received at least 26 injections for 13 diseases administered in combination and single vaccines — and as many as 38 counting the annual flu shot.
In his busy Toronto office, Dr. Moshe Ipp toils on the front lines of the vaccination war.
On this day, Julie Malone nuzzles 2-month-old Jonah as Ipp wields a syringe for the baby’s first five-in-one inoculation against diphtheria, polio, tetanus, pertussis and Hib (which causes meningitis).
After 32 years of practice, the pediatrician says he has perfected his technique (he figures he takes an average of nine-tenths of a second per shot). But his deft hand doesn’t impress Jonah, who throws back his fuzzy head and wails.
Ipp waits for Jonah to settle down, then swabs the other thigh before injecting the vaccine against pneumococcal disease, which stings even more because of its acidity.
Malone, 27, hadn’t been looking forward to this moment.
“But we think it’s important to vaccinate,” she says. “The biggest factor for me is the knowledge of how sick some of these diseases can make you.”
As a respiratory therapist, she’s seen patients with whooping cough struggle for breath and adults with chickenpox in intensive care.
Ipp inoculates 20 youngsters a day. He says 2 per cent of his 2,000 active patients delay, modify or refuse vaccination. The rest require more time and hand-holding than they used to. Ipp doesn’t turn away patients who won’t comply but requires them to sign a “refusal to vaccinate” form acknowledging the choice might endanger the health or life of their child and others.
A survey of 852 parents sponsored by the Ontario College of Family Physicians last summer found that 79 per cent believed the dangers of infectious diseases outweighed concerns about immunizing. But a third of those who planned to vaccinate were nervous about it, and almost a quarter called it a difficult decision.
No vaccine is 100-per-cent effective or risk-free. And today’s parents tend to weigh the odds differently than previous generations. They see vaccination as a matter of private choice rather than public responsibility.
The big danger of an under-immunized population is that a preventable disease could arrive on the next flight at Pearson International Airport.
Last April, a polio outbreak in Tajikistan, apparently brought by a traveler from India, infected 560 people within four weeks. It was the first to occur in a region that had been certified as free of the disease and prompted a Canadian Medical Association Journal warning against complacency about vaccination in a June editorial.
“This was a real wake-up call for those of us in polio-free countries,” says Dr. Noni MacDonald, a pediatric infectious-disease specialist from Halifax and one of the journal editors who co-authored the editorial.
The writers stressed that herd immunization coverage of 90 per cent is required and noted that Tajikistan’s rates had fallen to about 80 per cent. Most recent data from Ontario shows 83 per cent of 7-year-olds and 94 per cent of 17-year-olds are immunized against polio. “Enclaves of resistance (across the country) to vaccination represent a real threat,” the writers said.
This year, California has posted its worst invasion of pertussis since 1955, resulting in 4,100 cases and the deaths of nine babies. Hundreds of cases have been also reported in New York State.
Measles infected 84 people in British Columbia last spring and 26 in Toronto during 2008. And three years ago, a mumps outbreak that began in Nova Scotia led to 900 cases across the country, spread by university students heading home for summer.
Trish Gingerich of Scarborough was a true believer in immunization to prevent such outbreaks. She quickly got on board when the province decided to fund Gardasil, a vaccine to prevent the virus HPV (human papillomavirus, which can lead to cervical cancer), for Grade 8 girls. Her daughter, Alycia, then 13, received her first shot in December, 2008, and complained of soreness at the injection site and a headache for a few days. Two weeks later, she developed severe bruising and was rushed to hospital, where her platelet count (the clotting factor in her blood) had plunged to dangerously low levels, risking hemorrhage.
Gingerich says her daughter was diagnosed with chronic immune thrombocytopenic purpura (ITP) and hospitalized four times over the following six months for treatment to restore her platelet count.
ITP is a rare condition that can appear during the early years at a time when children receive most of their shots, says Dr. Melanie Kirby-Allen, a staff haemotologist at the Hospital for Sick Children, where Alycia was treated.
She wouldn’t comment on the case specifically but said ITP can happen randomly, so it’s not always clear whether it is a coincidence, related to vaccines or whether a vaccine might trigger the condition in someone predisposed to ITP. In some cases, the antibodies that are stimulated to fight off a disease by a vaccine can attach themselves to platelets, prompting the spleen to remove them, reducing the platelet count. She said the condition is treatable and usually resolved within a few months.
“We’ve seen it post-vaccination but it’s hard to speak in generalities about it because it is so rare,” says Kirby-Allen. She says the benefits of immunizing outweigh the risks of such rare reactions.
That’s cold comfort to Gingerich, who says her faith in the system has been shaken and she now worries every time her daughter gets a bruise. She says she would never want Alycia vaccinated again for any disease. Nor would she be immunized herself.
Gingerich says the ITP was officially reported to Health Canada as an “adverse event following immunization” and that she also wrote letters to federal and provincial health authorities. “I would like to see somebody accountable and the public to know about the risks.”
That’s also what groups opposed to mandatory immunization have been fighting for, as well as compensation for Canadians injured by vaccines and public access to information about adverse events that have been reported.
“We’ve never said ‘Don’t vaccinate your children.’ We advocate informed consent,” says Edda West, a B.C. grandmother and co-ordinator of the Vaccine Risk Awareness Network. The group gives a voice to parents of children injured by immunizations and questions some of the claims about vaccines made by public-health authorities.
The challengers have fought hard to win change. In the U.S., the push for safer diphtheria-pertussis-tetanus shots by groups like the National Vaccine Information Centre led to a revised pertussis formula that caused fewer adverse reactions. They raised questions about thimerosal (a type of mercury used as a preservative) and got it removed from all vaccines. Now it’s present only in the flu vaccine.
As more vaccines come on-stream, authorities must focus on providing parents with access to clear information, including vaccine ingredients and possible side effects, says Dr. Kumanan Wilson, Canada Research Chair in public health at the University of Ottawa and Ottawa Hospital Research Institute. Otherwise, expect big resistance from parents. When the HPV shot was introduced, fewer than half of Ontario girls received it. The 28-per-cent turnout for H1N1 last year in Ontario reflected a similar reluctance.
This month, the Canadian Pediatric Society recommended a new infant vaccine for rotavirus, the most common cause of diarrhea. And there are more to come. In the next 10 or 15 years there could be as many as 30 vaccines available for children, says Dr. Andrew Potter, director of VIDO-Intervac in Saskatchewan, which develops new vaccines.
There will also be less stressful ways of getting antigens into small bodies. This season’s flu vaccine, for example, is available in a nasal mist for ages 2 and up. There is also one that uses tiny intradermal needles injected under the skin surface rather than into the muscle, causing less pain. Skin patches and oral drops are in the works, along with vaccine formulations that last longer, requiring fewer doses, and more combination shots.
Where the saturation point lies and what all this flood of information means for conflicted parents like Nadine Silverthorne is unclear.
She feels the clock ticking as Nate’s 6th birthday approaches and she must decide whether to book an appointment for the four-in-one booster required between ages 4 and 6 or request an exemption so he won’t be barred from school. Should she play her part in a system aimed at protecting the community? Or should she wait until her kids are older when, she believes, “their systems are able to withstand it better.”
She continues to weigh and assess the relative risks, knowing that either way she is playing the odds. In the meantime, she says, “you’ve got to have all your fingers crossed.”
To jab or not to jab
Herewith, a few sites, publications that offer a solid grounding in childhood immunization:
• Canadian Immunization Guide from the Public Health Agency of Canada (phac-aspc.gc.ca/publicat/cig-gci)
• Canadian Pediatric Society(cps.ca). Clicking on Children’s Health Topics will take you to the Immunization page
• Canadian Immunizaation Awareness Program ) (immunize.cpha.ca)
• Your Child’s Best Shot: A Parent’s Guide to Vaccination, by Dr. Ronald Gold, available at Canadian Pediatric Society(cps.ca). Clicking on Publications and Resources will take you to the Bookstore.”
• Website and blog of Dr. Robert Sears (askdrsears.com/thevaccinebook), the author of The Vaccine Book, which includes a modified vaccination schedule for anxious parents.
• Vaccine Risk Awareness Network (vran.org) offers a good sense of the arguments put forward by groups concerned about potential risks and side effects.
• Frontline: The Vaccine War , pbs.org/wgbh/pages/frontline/vaccines is an excellent PBS film on the vaccination debate.
Source:
http://www.thestar.com/article/886973--as-roster-of-vaccines-grows-so-does-backlash-from-parents
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